COVID-19 Post-Vaccine Questionnaire Thank you for participating in the COVID-19 vaccine study. Please fill out the post-vaccine questionnaire below. COVID-19 Post-Vaccine Study Questionnaire Your Contact Information Full Name: * E-mail address: * Phone number: * Current date: * Vaccination Information Have you already participated or are you scheduled to participate in the COVID-19 vaccine study? (Sterling IRB ID: 8291-BZhang) * Yes No Have you completed all COVID-19 vaccine doses? * Yes No Have you received a COVID-19 booster shot? * Yes No Important! This questionnaire should be completed at least 1 week after receiving the final COVID-19 vaccine dose or at least 5 days after receiving the COVID-19 booster shot. What was the manufacturer of your COVID-19 vaccine? * Pfizer-BioNTech Moderna Johnson & Johnson What was the date of your last COVID-19 vaccine dose? * What was the manufacturer of your COVID-19 booster shot? * Pfizer-BioNTech Moderna Johnson & Johnson What was the date of your COVID-19 booster shot? * Side Effect Information Even though you were not diagnosed with COVID-19, do you think that you were, at any time, infected with COVID-19? * Yes No Did you experience side effects after receiving the first shot? * Yes No How long did your side effects last after receiving the first shot? No symptoms 1 – 3 days Up to 1 week Longer than 1 week Tiredness/fatigue * None Mild Moderate Severe Chills * None Mild Moderate Severe Fever * None Mild Moderate Severe Pain Pain at injection site * None Mild Moderate Severe Muscle pain * None Mild Moderate Severe Joint pain * None Mild Moderate Severe Chest pain * None Mild Moderate Severe Stomach pain * None Mild Moderate Severe Rash or Swelling Rash at injection site * None Mild Moderate Severe Swelling at injection site * None Mild Moderate Severe Redness, swelling, or itchiness outside of the injection site * None Mild Moderate Severe Swollen lymph nodes * None Mild Moderate Severe Leg swelling * None Mild Moderate Severe Neurological Headache * None Mild Moderate Severe Blurred vision * None Mild Moderate Severe Gastrointestinal Nausea/Vomiting * None Mild Moderate Severe Diarrhea * None Mild Moderate Severe Shortness of breath * None Mild Moderate Severe Fast-beating, fluttering, or pounding heart * None Mild Moderate Severe Did you experience side effects after receiving the second shot? * Yes No Not applicable. I got the Johnson & Johnson vaccine. How long did your side effects last after receiving the second shot? No symptoms 1 – 3 days Up to 1 week Longer than 1 week Tiredness/fatigue * None Mild Moderate Severe Chills * None Mild Moderate Severe Fever * None Mild Moderate Severe Pain Pain at injection site * None Mild Moderate Severe Muscle pain * None Mild Moderate Severe Joint pain * None Mild Moderate Severe Chest pain * None Mild Moderate Severe Stomach pain * None Mild Moderate Severe Rash or Swelling Rash at injection site * None Mild Moderate Severe Swelling at injection site * None Mild Moderate Severe Redness, swelling, or itchiness outside of the injection site * None Mild Moderate Severe Swollen lymph nodes * None Mild Moderate Severe Leg swelling * None Mild Moderate Severe Neurological Headache * None Mild Moderate Severe Blurred vision * None Mild Moderate Severe Gastrointestinal Nausea/Vomiting * None Mild Moderate Severe Diarrhea * None Mild Moderate Severe Shortness of breath * None Mild Moderate Severe Fast-beating, fluttering, or pounding heart * None Mild Moderate Severe Compared to the first shot, how were your side effects and symptom severity following the second shot? * Similar Less severe symptoms More severe symptoms Did you experience side effects after receiving the booster shot? * Yes No Tiredness/fatigue * None Mild Moderate Severe Chills * None Mild Moderate Severe Fever * None Mild Moderate Severe Pain Pain at injection site * None Mild Moderate Severe Muscle pain * None Mild Moderate Severe Joint pain * None Mild Moderate Severe Chest pain * None Mild Moderate Severe Stomach pain * None Mild Moderate Severe Rash or Swelling Rash at injection site * None Mild Moderate Severe Swelling at injection site * None Mild Moderate Severe Redness, swelling, or itchiness outside of the injection site * None Mild Moderate Severe Swollen lymph nodes * None Mild Moderate Severe Leg swelling * None Mild Moderate Severe Neurological Headache * None Mild Moderate Severe Blurred vision * None Mild Moderate Severe Gastrointestinal Nausea/Vomiting * None Mild Moderate Severe Diarrhea * None Mild Moderate Severe Shortness of breath * None Mild Moderate Severe Fast-beating, fluttering, or pounding heart * None Mild Moderate Severe Compared to the first shot, how were your side effects and symptom severity following the booster shot? * Similar Less severe symptoms More severe symptoms Compared to the second shot, how were your side effects and symptom severity following the booster shot? * Similar Less severe symptoms More severe symptoms Compared to the second shot, how were your side effects and symptom severity following the booster shot? * Similar Less severe symptoms More severe symptoms By clicking the “Submit” button below, I certify that the above answers are true to the best of my knowledge. If you are human, leave this field blank. Submit
